tkakin

Thank you very much Malcolm- your response eases my mind...and heart burn.

Thank you very much Malcolm- your response eases my mind...and heart burn.

Wouldn't a second type on an Oh patient be just as likely as the first to simply appear (erroneously) as group O, if using standard ABO typing methods? Am I missing something? 

It certainly is if your patient is not a true group O, but is of the rare Oh type.  It might just save you killing them!

It is best from an operational standpoint to do the same thing every time.  If you always do a second type on patients without a history, you won't forget to do one.

This is a CAP and AABB requirement. We get a new tube on any inpatient, OR patient, or ED patient whether they are getting blood or not. That way if they do need blood, we already have the second type. The tube should be drawn by a second person at a different time.

When I first joined the wonderful world of blood transfusion, with particular reference to blood group serology, at the International Blood Group Reference Laboratory, when it was in London, my mentors were Dr Carolyn Giles and Joyce Poole.  In those days, yes, we did use microscopes (albeit with very little magnification) and, given that we were using human-derived antisera, and the fact that I was anxious not to miss anything, I often got Joyce to check my sightings down the microscope.  These were invariably "kissing cells", as you suggest, and Joyce christened them "Malcolm weaks", a term which, I understand, is still used in the Red Cell Reference Department, when there is actually no agglutination present at all!
By the time I retired, I NEVER used a microscope for red cell reactions (of course, for Kleihauers and the like), but not for agglutination, unless I was training someone, and showed them the typical "mixed-field" agglutination seen with anti-Sda (I hate not being able to use subscript and superscript on herre any more) and Lutheran antibodies.

I don't believe that an optical aid necessarily refers to a microscope. In my pre-retirement years we used the agglutination viewer when an optical aid was required. Example: https://www.fishersci.com/shop/products/fisherbrand-tube-agglutination-viewer-5-watt-bulb-w-magnifying-mirror/22363560

I validate the probe thermometer with my NIST thermometer (2x/yr) - in all my storage devices.  Have not used an internal thermometer in years.  Never had a problem with CAP or AABB inspections.

I see your point, but if this was to happen I could put in a separate thermometer to trouble shoot it, right?  If the continuous probe is out for what ever reason it should alert me, and then I could put an internal therm in the device.  And if it doesn't alert me, then having the internal probe is only useful when I look at it.  
If there is no regulation that requires the internal therm then, I do not see its purpose except to trouble shoot, and it that case I would only use it when I need it.

Sorry, the requirement is internal, I should have been more clear.  We manage many transplant patients as we support a large cancer center.  They often get ABO mismatched transplants and we don't want to hemolyze the new cells or create more back type confusion than needed.  All mismatched transplants have some type of ABO restrictions on their cells and plasma and we always honor it.  That requires us to wash platelets.
Are they an inferior product, I assume so.  Are there fewer platelets than in the original bag?  Of course.  Our medical staff have determined this is the best product for the patients.

Yes, there is a fair modest platelet loss in washing, and the expiration is shorted to 24 hours, or the original date (whichever is sooner); however, we (I work with @Ward_X) don't always have A or AB platelets and for transplant patients of mismatched types, we always honor the requirement to provide compatible products.  Something that means washing a product.
An interesting side note.  We recently started accepting PAS platelets and if needed will wash them.  ICCBBA did not have a code for that so our IT people had a new code created.

Testing the same specimen twice may detect some internal testing errors, but will not detect WBIT (Wrong Blood In Tube).
You need to gather some data to show how many patients would be impacted by collecting a second blood sample. 
Ask these questions, "How many patient admits annually?", "How many patient admits required blood bank testing?" (at my facility the calculated percentage was 11%), "How many patient samples type as Group O?" (at my facility the calculated percentage was 55% and we don't draw a second blood sample on these patients), "Of the non-Group O patients, how many had an independently collected blood sample in Hematology that could be used for the second ABO blood sample" (in our facility that was calculated to be 16%).  
So for every 1000 patients admitted annually, 100 (I'm using 10% for sake of simple calculations) would require blood bank testing of whom 45 (100-55) would be non-group O, 7 (45 x 0.16) would have a blood sample in hematology, leaving  38 (45 - 7) or 3.8% (38/1000) patients requiring a second sample to be collected.  
Using this kind of data will give you a much better grasp of the impact of routine performance of a second ABO determination on all patients for whom a Type and Screen or a Type and Crossmatch is ordered.

If at all possible, they would have to consult with our pathologist.  Then beyond that, the physician in charge of the case would have to provide documentation that it is an emergent situation and that they are aware that they are transfusing incompatible product.
Having said that, it seems like it would be a really bad idea.  Giving A plasma to an unknown is one thing, but O plasma?
Scott

This does not happen often at my facility, but our policy is similar to AMcCord's.  If already infusing, the nurses continue the transfusion and document that.  If not infusing on arrival, we are rarely notified prior to the ambulance departing, so we rarely get to send the units back.  If there were appropriate shipping conditions/paperwork, then we would accept into our inventory; if not then the units are discarded and the transferring facility notified.

They should have, or create a policy to replace/reattach the armband. Get your pathologist and QA involved. 

We are not phenotypically matching units unless the DTT treatment does not work or they have developed an antibody.

Thank you all for your response.  I just realized I asked if you would order a fetal screen, but it should be a KLEI if they are weak D +. 
 

I remember John Judd once advising me to titrate an anti-M suspected to have an IgG fraction and not worry about separating the IgG from the IgM unless the titer became significant. Then we could titrate it after destroying the IgM if need be to see what the true IgG titer was.  It never exceeded something like 8 so we never had to send it out for additional testing.  These seems something like that--drawing a line of what is safe to save the cost of extra testing. Only do the additional testing when it is no longer safe to avoid it.  You would have to determine how you will turn it out so as to not overly confuse the OB/perinatologist.  "Titer against c, E, Fya, Jkb and S positive cell = 8"? Then next time when it is 16 with a cell of that phenotype, you would repeat separate titrations and results would be "titer against c & E positive cell = 8 & titer against Fya, Jkb and S positive cell = 4"? Or do you then go to separate cells for all of them but the E & c?  Or turn it out as 16 and they quit using titers to monitor?  I can see some logic to moving to ultrasound monitoring as soon as the cumulative titer is above 16 or so but we also like to watch how titers change over time to help us guess which antigens baby is positive for.  If you already tested amniocytes for antigens that would be moot but if you have only serology to go on you could miss some clues.  We titrate E & c together because they are likely to be inherited together and separate E+, c- cells are hard to find.  It also depends on if you can reliably find the same phenotype of cells for the next titration (we don't have the perfect world of using the same specific donor cell for the entire pregnancy).   Maybe it also matters if you know dad's phenotype/genotype.  If he is R2r then baby could be c+ E- but not if he is R2R2.   Sorry to ramble on; surely someone with more experience in this than I can answer with something more substantive but I've enjoyed speculating. 

You could try 56'C heat elution method. Though this is better for IgM antibodies it usually works with IgG, but does take longer. See AABB Technical Manual Method 4.3

We report the newborn to be Rh Indeterminate, with a comment that the newborn is treated as if Rh Positive for purposes of determining the mother's RhIg candidacy.  Additionally, the newborn may be tested in 4-6 months to determine the baby's true Rh type.

Report as Rh Indeterminate and treat as Rh+ for RHIG coverage of the Mom

We called the screen positive (went ahead and reported the gel screen) because we wanted the computer to prevent electronic crossmatch if they wanted more blood while that specimen was still good on a later shift that hadn't heard about her and didn't read her comments.  We were giving her units negative for the 2 antigens that she lacked (good thing that she was heterozygous for most of our "usual suspects") so we didn't want random units to be issued inadvertently.  Also, I read that patients on these drugs sometimes have a drop in H&H at first dosing so I wasn't really willing to go out on a limb and call them compatible and imply that they would have normal red cell survival.

I have used the Sarstedt SAHARA III for many years and they are very good, with regards to limitations I am not aware of any as such, they use dry heat to thaw the plasma and I don't ever remember one breaking down in the 3 different labs I have used them in. Maintenance is limited to wiping down the unit every week and cleaning out when you get a burst bag but they have a tray in the bottom to catch any leakage, I would take one any day over any water bath options. My current lab has an Helmer, I find it very slow compared to the SAHARA.  

I keep a notebook with calibration certificates in it. I also have a reminder on my on line calendar that comes up about 4 weeks before the calibration on that item expires. When I see the reminder(s), I order new thermometers. Ditto for the stop watch. Those things are not big budget items. Once they come, new thermometers go into service, old ones are removed and discarded, new certificate goes in notebook, old certificate goes into archive file. I decided a couple of years ago that I am too hard pressed for time to check calibrations on things like thermometers. Biomed has put my scale (for the Echo) and the tachometer on the list of things that their outside contractor checks yearly. My pipettes get sent out for calibration check - one of our evening techs is responsible for that, so all I have to do is check the certificate and file it in my notebook. When the inspector wants to see that stuff, it's all in one place.
Prior to this, I had a simple spreadsheet with all of the thermometers on it, listed by serial number. Each year I used a fresh copy of it. Part of the thermometer ID was where it was at. If it got moved, I changed that info on the spreadsheet, so at least I could find them. If they failed the annual check, I would note that and indicate that they were removed from service on that document. Once removed from service, that one was removed from the spreadsheet and the replacement was added.  Those went into my notebook.
I make a note at the top of each item's calibration certificate the date it is placed into service and the date it is removed from service. I don't have a huge number of these types of things, so it works for me. If I had more, I think I'd add a 'permanent' spreadsheet for tracking everything that documented in service date, removal from service date, and anything else that seemed important - just adding new lines for new stuff to the bottom of the ever growing list. I'm trying to put as much of those kinds of documents as I can into MediaLab to make review/approval documentation easier.